Infection control professionals
Infection control professionals (ICPs) play a critical role in implementing and managing healthcare-associated infection reduction interventions, whereas frontline staff are responsible for delivering direct and ongoing patient care. The objective of our study was to determine if ICPs and frontline staff have different perspectives about the facilitators and challenges of central line-associated bloodstream infection (CLABSI) prevention program success. Methods: We conducted key informant interviews at 8 hospitals that participated in the Agency for Healthcare Research and Quality CLABSI prevention initiative called “On the CUSP: Stop BSI.” We analyzed interview data from 50 frontline nurses and 26 ICPs to identify common themes related to program facilitators and challenges. Infection control professionals Results: We identified 4 facilitators of CLABSI program success: education, leadership, data, and con- sistency. We also identified 3 common challenges: lack of resources, competing priorities, and physician resistance. However, the perspective of ICPs and frontline nurses differed. Whereas ICPs tended to focus on general descriptions, frontline staff noted program specifics and often discussed concrete examples. Conclusions: Our results suggest that ICPs need to take into account the perspectives of staff nurses when implementing infection control and broader quality improvement initiatives. Further, the deliberate in- clusion of frontline staff in the implementation of these programs may be critical to program success. Infection control professionals
Copyright � 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
A central line-associated bloodstream infection (CLABSI) can occur when a central venous catheter, a procedure often asso- ciated with intensive care unit (ICU) settings,1 is not inserted correctly or not maintained properly. CLABSIs result in significant financial and nonfinancial costs to health systems and society because such infections increase risk of prolonged hospitaliza- tions, morbidity, and death.2,3 Fortunately, the implementation of standardized, evidence-based protocols can lead to dramatic and sustained reductions of CLABSIs in hospital ICUs.4-8 However,
ney, ScD, MS, Department of University, 2231 N High St,
201. McAlearney). the Agency for Healthcare Infection control professionals
). The views expressed in this present any US government e affiliated. ency for Healthcare Research
tion for Professionals in Infection
success rates vary between organizations.8,9 Some hospitals have virtually eliminated CLABSIs, and have sustained a rate of 0 infections for more than 24 months, whereas others have had less consistent results.10
Infection control in hospitals and their ICUs is extremely chal- lenging. Many people are involved (nurses, physicians, adminis- tration personnel, patients, and their families), and this certainly contributes to the problem of infection control. For example, these different individuals and groups of providers may have different opinions about how to reduce healthcare-associated infection (HAI) rates. Infection control professionals (ICPs) play a critical role in leading HAI-reduction interventions, and are responsible for the implementation and ongoing management of such interventions across hospitals and their ICUs. At the same time, frontline staff are responsible for delivering direct and ongoing patient care, and must determine how to incorporate infection control interventions within daily practice. Infection control professionals
Single hospital case studies of CLABSI reduction programs have engaged frontline staff in intervention design and implementation
Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Table 1 Interview questions about facilitators and challenges of healthcare-associated infection (HAI) initiatives
� Do you have any stories about barriers to introducing and implementing these HAI efforts at this organization?
B How were these barriers overcome?
� Were there new problems introduced with the implementation of the HAI initiative?
B How did these problems get resolved? B Do any of problems or barriers remain? B What could have been done differently to improve what happened with
these changes? Infection control professionals
� Were there things that occurred before implementation of these HAI efforts that needed to be addressed to facilitate implementation?
� What were the most important things that you think went well with intro- duction and use of the HAI initiative?
B What went right with this introduction of HAI efforts in this organization?
� What suggestions do you have for improvements in the use of these HAI initiatives?
B Do you have ideas about how work roles could be changed to improve the process?
B Do you have other ideas about how the process could be improved? Infection control professionals
A.S. McAlearney, J.L. Hefner / American Journal of Infection Control 42 (2014) S216-S222 S217
and reported this as a critical success factor.11,12 Further, leader- ship has been a frequently mentioned attribute of success, and nonclinical factors such as leadership and management practices have been posited as a potential explanation for between- organization variability in program outcomes.8,13,14 For ICPs to as- sume their critical leadership role in CLABSI prevention programs, they must understand the perspective of frontline staff. Studies have suggested that there is potential for disparity in perspectives between managers and their clinical staff with respect to the implementation and effects of patient safety initiatives,15,16 but this area is largely understudied in the infection prevention literature.Infection control professionals
To advance this line of research, our study explored the ques- tion, do ICPs and frontline staff have different perspectives about the facilitators and barriers associated with implementation and effects of a CLABSI prevention protocol? We analyzed interviews with ICPs and staff across 8 hospitals that participated in a CLABSI prevention program funded by the Agency for Healthcare Research and Quality (AHRQ) called “On the CUSP: Stop BSI.” Comprehensive unit-based safety program (CUSP), is a formal model for translating CLABSI reduction evidence into practice. We wanted to examine if and how the perspectives of ICPs and frontline nurses varied to improve our understanding about the factors that may contribute to successful CLABSI prevention efforts.
Study data collection
We conducted a comprehensive qualitative study of 8 hospitals that participated in the same cohort of the AHRQ CLABSI prevention initiative, “On the CUSP: Stop BSI.” Across the 8 sites in our study, we interviewed 194 key informants with different jobs and roles in the hospitals. Among these informants were 50 frontline nurses, and 26 ICPs (including interviewees with job titles of infection preventionist; hospital epidemiologist; infectious disease physi- cian; coordinator of infection control; and directors, managers, and staff in infection control departments). We focused on the com- ments from these 76 informants because their roles in the orga- nizations are relevant to our research question focusing on the perspectives of ICPs and frontline staff.Infection control professionals
Interviews lasted 30-60 minutes, and the majority were con- ducted with at least 2 interviewers. We used a standard interview guide to ensure consistency in our data collection.With informants’ permission, all interviews were recorded and then transcribed verbatim to ensure accuracy and reliability. We received approval from the Institutional Review Board of The Ohio State University to conduct this study. For the results we report here, we focused on questions related to facilitators of and barriers to CLABSI prevention efforts to compare the responses of ICPs and frontline staff. These interview questions are shown in Table 1.Infection control professionals
We analyzed our data using a combination of inductive and deductive methods.17 We reviewed notes and transcripts from in- terviews as the study progressed and discussed preliminary find- ings. Themes emerged from these ongoing discussions and allowed us to develop additional question probes to include in subsequent interviews. At the conclusion of data collection we developed a coding dictionary with main coding themes and specific subcodes with detailed definitions specifying when to apply those codes. The lead study investigator and two research assistants coded the transcribed interview data using this dictionary. Throughout the coding process the research teammet periodically to discuss issues, resolve discrepancies, and develop new codes and definitions for
emergent themes and subthemes. We used Atlas.ti qualitative analysis software (Leicester, United Kingdom) to support all parts of our analysis.Infection control professionals
Across sites and informants we found four facilitators of CLABSI prevention initiatives, with perspectives about these facilitators varying between ICPs and frontline staff. We also identified 3 main challenges of CLABSI prevention programs, characterized differ- ently by respondent group and 2 additional challenges identified only by ICPs. Below we describe our results in greater detail. We provide additional evidence supporting our characterization of these facilitators and challenges with representative verbatim comments presented by theme and by respondent type in Tables 2 and 3.
Facilitators of CLABSI prevention initiatives
We found 4 facilitators of CLABSI prevention commonly mentioned across interviewee groups: education, leadership, data and technology, and consistent clinical processes. These facilitators were noted across sites, and their absencewas oftenmentioned as a barrier to CLABSI prevention. Interestingly, whereas both inter- viewee groups identified these 4 facilitators, groups’ perspectives about these facilitators differed. For 3 of these 4 facilitators, we also identified subcategories of facilitators within the larger theme category, as we describe in further detail below. In Table 2 we present verbatim quotations as additional evidence about the salience of these facilitator themes and subthemes, by interviewee group.
Education We found 2 main subthemes associated with education as a
facilitator of CLABSI prevention: the importance of staff education and reeducation, and the importance of an inclusive education process. Both the ICPs and frontline staff emphasized the impor- tance of continuing education, but the focus differed between the Infection control professionals
Table 2 Representative comments characterizing facilitators of central line-associated bloodstream infection (CLABSI) prevention initiatives, by interviewee group
Theme Verbatim comments from infection control specialists Verbatim comments from frontline staff
Subtheme Education Staff education and reeducation Emphasis on learning from mistakes
“How do we move forward so this doesn’t happen again? I think that whole process of letting them know is really key.”
“Definitely keep everyone in the loop. Don’t just report it out and move on. Let the people involved know ahead of time, so it wasn’t or maybe it was, maybe something was going on.”
Emphasis on continuing education “Continuous education.The proper way. Sometimes we
forget. Always a reminder of the proper way of changing the dressing, when the dressing needs to be changed. Scrubbing the hub. .Even the simple things you think we would remember, but, you know.”
“Education definitely. And make it frequent.. Newsletters, they use newsletters, which are great because you can pull those up on your own personal time. You can’t always do things here and I knowwhen I go home and I read an e-mail that has a link and then you can get the update. So education is definitely important.”
Inclusive education Multidisciplinary education process “We also have noticed, going back to CLABSI, where there Infection control professionals
was some education needed with anesthesia or the operating room nurses as they accessed these lines. But it kind of helped that we already had a relationship built in with some of these operating room folks because we have to address line access.”
“I think it’s a combination of all of the education, the collaborative.”
Include patients in education process “And we also tell the patients. I tell the patients after I’ve
put a line into them or if I’ve done a dressing, ‘Make sure that anyone who touches you washes their hands before they touch you.’ I tell them all the time, ‘Make sure that whoever’s taking care of you washes their hands.’ They can use the alcohol if they want.”
“I think the most important is involving everyone and the patient.”
Leadership Attention from administration Engagement with supportive leadership
“We’ve gotten more administrative support for making our recommendations Infection control professionals
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